Claudia, a case history of intensive behavior analysis and behavior change

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Claudia, a case history of intensive behavior analysis and behavior change
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ix, 183 leaves : ill. ; 28 cm.
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Hartman, William Mark, 1950-
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Behavior therapy -- Case studies   ( lcsh )
Child psychology -- Case studies   ( lcsh )
Psychology thesis Ph. D   ( lcsh )
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Thesis--University of Florida.
Bibliography:
Includes bibliographical references (leaves 174-182).
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Also available online.
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Typescript.
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Vita.
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by William M. Hartman.

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Table of Contents
    Title Page
        Page i
    Dedication
        Page ii
    Acknowledgement
        Page iii
        Page iv
    Table of Contents
        Page v
        Page vi
    Abstract
        Page vii
        Page viii
        Page ix
    Chapter 1. Case histories and the present study
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
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    Chapter 2. Claudia: A case history of intensive behavior analysis and behavior change
        Page 26
        Page 27
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    Chapter 3. Determination of visual threshold
        Page 154
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    References
        Page 174
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    Biographical sketch
        Page 183
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        Page 186
Full Text












CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR

AN.AT YS IS AND BEHAVIOR CHANGE



















By

William M. Hartman














A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA
IN, PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR 'THE
DEGREE OF DOCTOR OF




UNIVERSITY OF FLORIDA
19-119





















To my friends and teachers of the science of human behavior, Claudia and Hank.














ACKNOWLEDGEMENTS


There are so many people to whom I am indebted that in thanking some individuals, I run the risk of oversight. Two notable omissions are, however, intentional: I have instead dedicated this work to them.

I would first like to thank my committee, Drs. Marc

Branch, Mark Goldstein, James Johnston, John Newell, Dorothy Nevill, and Henry Pennypacker. They provided guidance and encouragement in a project that had considerable personal, as well as professional, meaning to me. In addition, I am indebted to Drs. Calvin Adams and Ogden Lindsley for their aid in aspects of design and preparation, and to Ms. Vickie Barkmeier for her invaluable assistance in editing and preparing the manuscript.

I would also like to thank my entire family for their unfailing love and support. There is simply no way to even begin expressing my gratitude to and love for my parents. I can, however, thank my mother for her active interest in and help with my professional career, and my father for his incredible expenditure of time and energy in preparing the entire set of graphics for this paper.

Families are not limited to those to whom one is related. My thanks to the entire Pennypacker -Family for the home away from home they made for me.









There are also two men whose impact on me was profound and whom I wish to remember here, the late Zelig Sered and William Resnick.

I would like to extend special thanks to a special

group of people. I am lucky and proud to have been a part of

-the loving, caring team effort that was the STARS Program.

I am particularly indebted to one person. I would like L.o thank Ms. Lynda Ward, not only for the time and expertise she devoted to this work, but also for her support, her love, and for seeing me through.



































iv














TABLE OF CONTENTS

PAGE

ACKNOWLEDGEMENTS . . . . . . . . . . iii

ABSTRACT . . . . . . . . . . . . vii

CHAPTER ONE: CASE HISTORIES AND THE PRESENT STUDY . 1

Introduction . . . . . . . . . . I
Case Histories . . . . . . . . 2
Definition of Case History . . . . . . 2
Earliest Case Histories in Child Development . 5 Psychological Narratives . . . . . . 9
Qu initiative Data, Analysis, and Learning
Theory . . . . . . . . . . 10
Behaviorism . . . . . . . . . 10
Behavior therapy . . . . . . . 11
Operant conditioning . . . . . . 12
Studies of Retarded Individuals . . . o 13 J. M. G. Itard and the Wild Boy of Aveyron . . 16
Claudia: Rationale for and Technical Aspects of
the Case History . o . . . . . . . 20
Rationale . . . . . . . . . . 20
Technical Aspects . . . . . . . . 22

CHAPTER TWO: CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR ANALYSIS AND BEHAVIOR CHANGE . . o . . 26

Background: Claudia's First Seventeen Years . . 26
From Home to the Institution . . . . . 26
Life at Sunland . . . . . . . 27
The STARS Meet Claudia . . . . . . . 30
The STARS Program at Lilac Cottage . . . . 30 Initial Observations . . . . . . . 34
Rumination Baseline . . . . . . . 37
Designing the Rumination Procedure . . . . 40
Training Begins . . . . o . . . . 45
Results of the Rumination Procedure . . . 45 Building New Behaviors I: Eye Contact . . . 49 Building New Behaviors 11: Playing Catch . . 54 By-Products of the Early Training . . . . 58
Basic Self-Feeding, Skills . . . . . . . 60
Learning to Scoop . . . . . . . . 60
Fine Details of Scooping . . . . . . 62




v








PAGE

Learning to Walk . . . . . . . . . 69
Preparatory Programs . . . . . . . 70
The First Independent.Steps . . . . . 73
Rumination Redux . . . . . . . . . 79
Unmonitored Rumination . . . . . . . 79
Procedural Revision . . . . . . . 81
Reversal and Return to Intervention . . . 83
Advanced Ambulation Skills . . . . . . 90
Walking Outdoors . . . . . . . . 90
Auxiliary Skills I: Into and Out of Chairs . 92
Auxiliary Skills II: Standing Up from the
Floor . . . . . . . . . . . 97
The Daily Constitutional, Part I . . . . 100 The Daily Constitutional, Part 11 . . . . 106 Auxiliary Skills III: Climbing Stairs . . . 109 Auxiliary Skills TV: Crossing Obstacles . . 115
The Campus Cafeteria . . . . . . . . 119
Getting There . . . . . . . . . 119
Eating Skills in the Cafeteria . . . . . 121 The Serving Line and Carrying the Tray . . . 126
Final Aspects of Training . . . . . . . 130
Exploring Out the Gate . . . . ... . 130
Expanding the Daily Constitutional . . . . 132 Social Behavior . . . . . . . . 133
The Limits of Training . . . . ... . . 136
Review of 'Training Discussed Heretofore . . . 137 Programs That Failed . . . . . . . 139
Programs Never Attempted . . . . . . 141
Determining the Limits of Training . . . . 143
Saying Goodbye . . . . . . . . . 146
The Author T eaves the STARS Program . . . 146 Claudia Leaves Lilac . . . . . . . 147
Final Considerations . . . . . . . 152

CHAPTER THREE: DETERMINATION OF VISUAL THRESHOLD . 154

Method . . . . . . . . . . . 156
Training the Basic Response . . . . . 156
Discrimination Training . . . . . . 158
Testing, Retraining, and Retesting . . . . 166
Results 168
Discussion . 171

REFERENCES . . .. . . . . . . . . 174

BIOGRAPHICAL SKETCH . . . . . . . . . 183







Va.














Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy


CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR
ANALYSIS AND BEHAVIOR CHANGE

By

William M. Hartmnan

December 1979

Chairman; Dr. H, S, Pennypacker Department: Psychology

The cost, effectiveness, and cost benefit of applying a

variety of intensive behavior change procedures were evaluated in a state residential institution for the retarded. Effec-'--iveness was measured in terms of appropriate changes .in response frequencies; costs were equated with time and money; and cost benefit was derived by the cost-avoidance resulting from the demonstrated increase in adaptive behavior. The study occurred over a period of approximately two and one half years and included over 6000 training and testing hours. The subject was a nonambulatory, self-abusive, profoundly retarded female adolescent. Training and/or analysis was conducted in five areas, as follows;

Decrease of self-abusive behavior (rumination); Analysis of diet indicated that rumination frequency was -At least partially dependent on liquid density and time of liquid intake.


vii









Changes in these parameters reduced rumination rate from 1.2 to 0.6 responses per minute. Addition of a rumination-contingent lemon Juice squirt, followed by a cheek-hold procedure, decreased the frequency to 0.003 ruminations per minute. A weight gain of 45 pounds accompanied the decrease in rumination.

Ambulation training: The following classes of behavior were instated (none were present prior to training): independent walking, up to one mile per day at over 100 steps per minute; independent chair use (into and out of chairs), at 7.0 times per minute in speeded practice trials; ascending and descending stairs, at 25 stairs per minute; crossing obstacles, at 6.0 times per minute in speeded practice trials.

Eating and related skills training: Independent scooping with a spoon was increased from 0.6 to 8.0 scoops per minute. Use of a cup was taught to terminal performance in practice trials of 8.0 correct uses per minute versus one or zero spills per five minutes. Training in cafeteria tray-carrying reduced the frequency with which materials on the tray were spilled from five times per minute to about once per minute, at which time totally independent tray-carrying was possible.

Motor skills training: A variety of skills was taught, including playing catch, with a terminal performance of 70 correct throws versus one wrong throw per ten minutes. Tricycle riding was a'-so trained assists to steer the tricycle were decreased from five to less than one per minute.



viii








Assessment of visual functioning: A modification of the constant-stimulus psychophysical method was used in a nonverbal discrimination task involving a white cube (S) and a white cube with a black circle (S-),, Lifting S+ and depositing it in a container resulted in reinforcement, and touching S- was followed by a brief timeout. The diameter of the Scircle was gradually reduced from 0.40 cm to 0.04 cm. From the resulting 75 percent correct threshold value of 0.08 cm,. acuity ratio was calculated as 2 0/130 (both eyes*).

Periodic follow-ups indicated that most major induced

changes maintained, particularly walking, independent eating, reduction in rumination rate, and weight gain.

Discussion included assessment of factors related to

maintenance of behavior change and a limited analysis of increased social behavior as a by-product of intensive training. In addition, qualitative and quantitative techniques were suggested for assessing the relative effectiveness and efficiency of training procedures and for determining maximal

skill levels in retarded persons.


















ix













CHAPTER I

CASE HISTORIES AND THE PRESENT STUDY


Introduction


This paper is a report of two and a half years of the

intensive study and training of Claudia, a profoundly retarded adolescent living in Sunland Center, Gainesville, Florida.1 The data included in the report were collected routinely as part of Claudia's participation in the STARS (Start Training Appropriate Responses to Stimuli) Program, a training project funded by Public Law (PL) 89-313.2

The material chronicles behavior analysis and behavior

change efforts in a variety of areas-- self-abusive behavior, motor skills, daily living skills, and determination of visual acuity threshold- and covers many specific behaviors. Since the analysis and modification of each behavior was highly dependent on the concurrent existence and rate of many other behaviors, the report is best presented in case history, roughly chronological form, rather than as a series of separate behavior analyses and behavior modification projects.



lPermission to use the data reported herein was granted May 26, 1978. A copy of the release form is on file in the Training Department Office, Sunland Center, Gainesville, Florida.
2The contents of t-his report do not necessarily reflect the views of the Department of Health, Education and Welfare.



1





2


The paper is divided into three major sections. Chapter one revolves around the concept of the case history, tracing the evolution of the case history in psychology and particularly in behavior analysis. This section considers the relationship between behavior analysis and behavior change, and concentrates upon reports of disabled (retarded, autistic,, etc.) individuals. Chapters Two and Three are Claudia's case history. As indicated above, the material is presented in approximate chronological order. The case history is subdivided according to training milestones, rather than into time periods of equal length. Traditionally-labeled sections-"setting," "procedure," etc.-- are omitted; all information that would normally appear in those sections is included in the narrative account to permit a more readable text.


Case Histories


Definition of Case History

A case history is an account of the intensive study of some portion of an individual's life. It is usually either a description of change (rehabilitation) efforts for a problem or a set of problems, or is a complete description or analysis of a set of target behaviors. when behavior analysis components (experimental manipulations designed to establish a functional relation among stimuli and responses) are included, the term 11 case study" may be used. However, the two terms are frequently used synonymously (e.g., Ullman & Krasner, 1965), with good reason: it is difficult to establish the point at which





3


description of behavior and behavior change ends and the experimental analysis of behavior begins (Johnston & Pennypacker, in press). For present purposes, several comments will suffice to demonstrate that behavior change/behavior analysis are best viewed as constituting a continuum; a particular case history may include data from any part or parts of that continuum.

The commonest form of treatment described in case

histories involves instituting a change in the subject's environment and observing whether behavior change follows. if the behavior changes, especially in the desired direction, the therapist is likely to conclude that there is a relation between the procedure and the observed change. The experimental reasoning is weak and clearly belongs at the "behavior change" end of the continuum. However, for therapeutic purposes the goal has been accomplished. The therapist may also wish to explore the alleged relation further, for a variety of reasons and in a variety of ways. The therapist may, for example, want to test the strength of the therapeutic effect, examine the degree to which the effect is maintained in different situations, and demonstrate necessity/sufficiency of various aspects of the procedure. The therapist's activities are now shifted toward the "behavior analysis" end of

the continuum.

The case studies described below cover a large portion

of the continuum. The degree to which each may be considered analytic depends upon the nature of the data-- diary,





4


narrative'log, observation scheduler behavioral frequency, etc.-- and upon the "experimental design" employed by the author. The designs vary by circumstance, ranging from "I wonder what my client will do if I suggest. .,"to highly sophisticated and incisive strategies as those described in research texts (e.g., Sidman, 1960; Johnston & Pennypacker, in press).

No effort will be made to rate the case histories' analytic value or quantify the continuum. In fact, many histories lack all but the crudest and most inferential data

and reasoning, but are valuable for other reasons such as providing pleasurable reading and, occasionally, inspiration.

The role of analysis has become crucial for at least

one group of case history producers and consumers-- the group included under the rubric of "behavior modification" (Kazdin, 1973). For this group, case histories of the most analytic form-- studies of individuals conducted explicitly to discover the laws of behavior-- comprise a portion of the experimental literature. In such experimental studies, emphasis is generally placed more upon graphic displays of data than upon narrative account, but the results may certainly be viewed as case histories. In addition, non-researchoriented modifiers or therapists regularly integrate various levels of analysis into their therapeutic endeavors. The amount and kind of analysis is-- or should be-- dictated by the needs of the case at hand.






5

The following sections provide a sample of the scope

and flavor of case histories, and a brief discussion of the potential and merits of the histories. Heaviest emphasis is placed upon the role of the case history in behavior analysis, especially in the training of disabled individuals.


Earliest Case Histories in Child Development

While earlier accounts of the behavior of individuals are available, Tiedxnann's (1787/1927) work is recognized as "the first attempt to make a series of scientific observations on the behavior of young children" (Tiedmann, 1787/1927, p. 206). Tiedmann's goal was to provide data for teaching "the development of the mind's powers"; he- noted that there was I"a dearth of exact and sufficiently numerous observations upon children's souls" (Tiedmann, 1787/1927, p. 205). To rectify the situation, he regarded detailed study of the individual as the best solution, with the following caveat:

I grant that what has here been observed
cannot be taken as a general law, since
children . progress variously ...
but at least it informs us of one among
the possible rates of progress.
When we shall have several such records
it will be possible by means of comparison to strike an average for the common order of nature. (Tiedmann, 1787/1927,
p. 206)l

Beginning in 1787, Tiedrnann observed and "experimented

upon an infant from birth to age two years, six months." His



ljohnston & Pennypacker (in press) describe the development of the view that social phenomena are subject to a natural law of averages, and the growth of statistics based on this view.





6


report was completely narrative and chronological, with extensive notes concerning the first several days and more infrequent observations-- about one per several months, *as relevant-- thereafter. His data were not quantitative,.but his observations and "experiments" enabled him at least to begin analyzing behavior. For example, in tracing the development of the sensation of taste, Tiedmann notes:

Even the special sensations of taste...
were not yet distinguished (at two days of
age) . . This appeared conclusively
on August 25. On account of an indisposition the boy was given a medicine of unpleasant taste and pungent odor; he took it
without any sign of objection, like his
usual food. . [T]hirteen days after his
birth the boy showed some traces of acquired
ideas, in clearer sensations and affections
of his soul. Some medicines were now unwillingly taken, with evident reluctance, yes,
were even spewn forth again, but not immrediately, rather upon being tasted several times.
(pp. 208-209)

Tiedmann frequently strayed beyond the limits imposed by his data to draw highly inferential conclusions, looking as he

was for "Proof of t-he superior original activity of the human soul" (p. 211). Nevertheless, his work was a dramatic, early demonstration of the potential of detailed study of the individual; i.e., the case history.

Although Tiedmann's study was perhaps the first published attempt at a scientific case history, the educator Pestalozzi had published a diary several years earlier (1774) documenting his efforts to teach his young son. While Tiedmann was interested in the description and analysis of various "naturally unfolding" behaviors, Pestalozzils diary was an early prototype





7


of case histories involving the description of individual intervention strategies. Although Pestalozzi was not concerned with detailed analysis of his procedures, he carefully observed the effects of instituting the procedures. He thus obtained at least a no-intervention vs. intervention analysis:

I left him no choice between his task
[boring, unhappily attended reading lessons] and my displeasure with the
consequent punishment of being confined
in a room by himself. After this he
gave way and learned his lessons merrily.
(Pestalozzi, 1774, in Green, 1912, p. 29)

Pestalozzi was also aware-- but did not pursue the study-of primary reinforcement. He maintained a supply of cooked apples which he distributed to his son, Jacques, "now and then." initially, Jacques wanted to eat all of them at once, but his father refused, using the opportunity to induce Jacques to study, telling him, "if he learnt well I would give him some more. He left the spoon alone," and proceeded with his lessons (p. 34).

Pestalozzi's diary, among his other works, made important contributions to the field of education. In addition to providing many examples of effective and ineffective instructional techniques (he recognized the value of reporting failure as well as success), the diary was a forerunner of the many current individual education plans, prescriptions, etc.

Shortly, after Tiedmann's and Pestalozzi's pioneering efforts, Itard published the results of nearly five years of studying and training Victor, the "Wild Boy of Aveyron"





8


(1801, 1806, translated by Humphrey & Humphrey, 1962), Victor, who was probably abandoned at about age three to live alone in the forests of France, was the best-known but not the firstreported feral child. At least ten such cases were reported between the mid-sixteenth and eighteenth centuries, and Linnaeus classified them as a distinct human species, Homo Ferus (Locke, in Pringle-Pattison, 1924; Rousseau, translated by Masters, 1964). However, the early reports of feral children were sketchy and unreliable; Itard's several publications

are combined to form the first complete case history of such a child. First Developments of the Young Savage (1801) and A Report Made to his Excellency the Minister of the Interior

(1806) combine Tiedmann's attempts at scienti fic analysis and Pestalozzi's description of educational intervention, to constitute what is arguably the finest case history ever written. The work will be considered in detail in a later section; it is mentioned here to note its place in the evolution of the case history.

During the remainder of the nineteenth and early twentieth centuries, case histories similar to those described above continued to appear. Darwin (1877), for example, published A Biographical Sketch of an Infant, a narrative based on the diary he kept of his son's first six months. The narrative is quite similar in form and content to Tiedmann's earlier work. Singh & Zingg in 1942 published an account of Singh's work in the 1920's with several feral children, and included a review of the earlier feral cases (Hahn, 1978).








Diaries and narrative logs thus comprised the earliest

data of the child development field (Arrington, 1939; Mussen, Conger, & Kagan, 1969; Lytton, 1971). Although behavioral time-sampling schedules became the most popular method of collecting data during the 1930's (Hartman, 1978), the case history remained a major vehicle for detailed study of the individual. For example, Barker's "psychological ecology" was centered around the "specimen record'," or "narrative account" (Barker & Wright, 1949). Piaget also used such accounts to support his theories of child development, although narrative records did not comprise the majority of his data (Flavell, 1963).


Psychological Narratives

The rise of psychoanalysis created great interest in

treatment-oriented case histories or "psychological narratives." Due to Freud's prolific writing, the case history assumed an integral place in psychoanalytic literature (e.q., Freud, 1955). Freud published six case histories based upon various types of information. "The Wolf Man" was a discussion of childhood neurosis, stemming from psychoanalysis sessions conducted while the patient was in his twenties. Another case history was based upon an autobiography; Freud never saw the subject. Freud used the case histories as proof of various aspects of his theories and as a setting for theoretical expositions. "Dora" for example, written much like a novel, demonstrated the value of dream interpretation in analysis (Jones, 1955).





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As the number of psychotherapeutic orientations grew, so-did the number of applications of the case history. In addition to appearing in professional journals and books, case histories and life stories were dramrratized and appeared in the popular literature, with appeal to professional and public tastes alike. Dibs in Search of Self (Axline, 1964),. Three Men (Evans, 1966) Sybil (Schreiber, 1974), and Children with Emerald Eyes (Rothenberg, 1977) are recent examples; their style and popular appeal were foreshadowed by Beers' autobiographical A Mind That Found Itself (1908). Quantitative Data, Analysi s and Learning Theory


Behaviorism. The foregoing case histories are, with

several exceptions, primarily treatment-oriented and descriptive. The emergence of behaviorism in the early 1900's (Watson, 1924) gave rise to a new type of case history-studies of individuals that incorporated, or even focused upon, analysis and/or quantitative data.

Watson and Rayner (1920), in their famous study of Albert and the white rat, recorded trial.-by-trial progress in conditioning and generalizing fear. Using similar methods,, Jones (1924) studied and treated another young boy's fear of various objects. Jones examined the effectiveness of gradually "fading in" the feared stimuli and noted the degree to which Peter responded to similar objects not involved in the deconditioning manipulations.

Skinnerian psychology (Skinner, 1938, 1953) placed

quantitative studies of individuals firmly within the realm of








scientific inquiry. E and recording
xperimental methods

techniques, developed in the animal laboratory, were soon applied to the analysis of human behavior (e.g., Fuller, 1949; Azrin & Lindsley, 1956; Bijou, 1955, 1957,1958) and continue to constitute an integral portion of the experimental literature (e.g., Barrett, 1965; Ferster & DeMyer, 1965; Findley, 1966; Emurian et al., 1978). These purely analytic endeavors, published in experimental format, are nevertheless highly detailed studies of individuals. As such, they may be correctly considered case histories, belonging at the "analytic" end of the continuum discussed earlier.


Behavior therapy. People involved in the treatment of behavior disorders quickly saw the relevance of the work of Watson, Skinner, and other researchers, and applied learning principles to clinical practice. In the late 1950's and 1960's, Wolpe, Lazarus, Eysenck, Shapiro, and others used case studies extensively as "proof" of and support for the validity of their various behavior therapy theories and techniques (e.g., Wolpe, 1958; Shapiro, 1966). Shapiro in particular supported the notion of single-case study for demonstrating therapeutic control of behavioral disorders.

The early case material heavily emphasized treatment and did not concentrate upon analysis; No-treatment vs. treatment comparison was the common form of case study. For "proof," the therapists relied upon large numbers of cases, or "reproductions" of the therapeutic effect, Lazarus (1963), for example, summarized the results of 126 cases of treatment of severe neurosis.





12


The relative merits of using this form of case history in lieu of more highly analytic studies, group or singlesubject design, were hotly debated (especially Breger & McGaugh, 1965, 1966; Rachman & Eysenck, 1966). The most reasonable conclusion rests upon the degree of analysis evidenced by a given case history: The studies reported by the behavior therapists did not offer conclusive proof of the effectiveness of the therapy techniques employed, but neither were the cases irrelevant; they were highly suggestive demonstrations that stimulated more analytic endeavors (Ullman & Krasner, 1965; Kazdin, 1978).


Operant conditioning. In addition to practitioners of the behavior therapies described above, another group of researchers/therapists included by the label "behavior modifiers" are those who have concentrated their analysis and treatment efforts within the realm of operant conditioning or Skinnerian psychology. This group, too, has used case histories extensively for analytic and treatment demonstration purposes. The settings, subjects, and behaviors studied vary widely. Heaviest concentration has been upon autistic, schizophrenic/psychotic, and retarded individuals residing in institutions, but home and outpatient settings for studies of normal and disabled individuals are notL uncommon (e.g., Williams, 1959; Rickard, Dignam, & Horner, 1960; Rickard & Dinoff, 1962; Ayllon & Azrin, 1965, 1968).

The studies have ranged from demonstrative,,one-phase (treatment) -only reports (e.g., Ayllon & Michael, 1959;









Wolf, Risley, and Mees, 1964) to highly analytic research employing multiple reversals and examination of the target response under multiple conditions (e.g., Allen et al., 1964; Hart et al., 19647 Rickard & Mundy, 1965; Rekers & Lovaas, 1974). The most common type of case history is the "AB" or no-treatment vs. treatment design (e.g., Ayllon, 1963, 1965; Patterson, 1965; Wolf et al., 1965). The scope of the studies has 'generally been limited, covering one, two, or three target responses for periods of about two weeks to a year.

The salient feature of these case histories is the

universal use of graphic displays of quantitative data regarding the target responses. Whether the studies are written in experimental or narrative format-- experimental is the more common-- the graphic data displays are generally the focus of the reports. The measurement indices vary greatly, including cumulative rec ords, tallies, frequency, and most often, percent measures-- percent time engaged in responding, percent trials containing a response, etc. The graphic displays, or more precisely, the data contained in the displays, make these case histories distinctive among the histories discussed heretofore in terms of both behavioral description and analysis.


Studies of Retarded Individuals

of particular interest to the present report are case histories and related analyses of the behavior of retarded persons, particularly the profoundly retarded.





14


In 1949, Fuller presented the first conclusive evidence that profoundly retarded individuals-- formerly designated "vegetative idiots"-- were susceptible to operant conditioning techniques. Fullerls study was not treatment-oriented; he demonstrated that a simple response, arm-raising, could be controlled by the contingent delivery of food. However, the implications for the treatment of the profoundly retarded were enormous-- subsequent case histories demonstrated that such basic living skills as feeding, ambulation, and other motor behaviors could be taught to these persons formerly regarded to be completely untrainable (e.g., Rice & McDaniel, 1966; Rice, et al., 1967; Barton et al., 1970; Loynd & Barclay, 1970). In addition to developing living skills, researchers and therapists demonstrated control of many of the undesirable behaviors that frequently accompany profound retardation: self-injurious behaviors, such as hand biting, head banging, and potentially lethal rumination (e.g., Kanner, 1957; Lang & Melamed, 1969; Sajwaj, Libet, & Agras, 1974; Cunningham & Linscheid, 1976; Harris & Romanczyk, 1976; Iwata & Lorentzson, 1976; Becker, Turner, & Sajwaj, 1978).

As is true of the studies reported in the previous

section, case histories of retarded persons range from unanalytic to highly analytic. The majority are demonstrations that a particular procedure controls a particular response; the most common designs are no-treatment vs. treatment (AB) or no-treatment vs. treatment, with a reversal (ABAB). While demonstrating a functional relation between a procedure and








a behavior has been common, fine-grain analysis, such as isolating the specific elements of a procedure responsible for control, is rare (e.g., Homer & Baer, 1978). For example, the relevant aspects of overcorrection procedures, popular in controlling self-injurious behavior, are not known (cf., Epstein. et al., 1974; Foxx & Azrin, 1973; Harris & Romanczyk, 1976). Likewise, some data indicate that appropriate behaviors emerge as aversive procedures decrease the rates of inappropriate behaviors, but the conditions under which and the degree to which this occurs are not well documented (e.g., Risley, 1968; Miller, Patton, & Henton, 1971). In comparison, there is clear indication that responses punished under one set of conditions may well occur at a high frequency in other (no-punishment) settings; even severely retarded individuals readily discriminate "safe" and "unsafe" conditions in which to emit the target behavior (Lovaas & Simmons, 1969; Rollings, Baumeister, & Baumeister, 1977).

Retardation case histories also evidence the same

general scope as do other case histories by behavior analysts. An "intensive" study might included measuring and modifying three responses over the course of several months (e.g., Miller, Patton, & Henton, 1971). There are two notable exceptions to this generally limited scope. One is Stoddard's (1971) studies of Cosmo, a profoundly retarded microcephalic. Stoddard conducted laboratory studies of Cosmo for nearly ten years in an exploration of behavior analysis teaching






16


techniques. The studies were generally not treatment-oriented in that most behaviors were laboratory-specific with no attempt to generalized to Cosmo' s living environment (e.g., visual discrimination; token training).

A second exception to the limited scope of case histories is Itard's description of the Wild Boy of Aveyron.


J. M. G. Itard and the Wild Boy of Aveyron

Although Itard worked with Victor, "L'enf ant savage," from 1801-1806, the work is discussed here because of its importance to retardation, the experimental analysis of behavior, and the development of the case history. First Developments of the Young Savage (1801) and A Report Made to his Excellency the Minister of the Interior (1806; both translated by Humphrey and Humphrey in 1960) together form the first case history in behavior modification (Lane, 1976). As will be seen, lthe work differs from modern behavior analysis case histories in two respects. First, there is no graphic display of quantitative data; Itard's reports are in narrative form with all "data" described in the text. Second, the technical terminology obviously differs from today's. Nevertheless, The Wild Boy of Aveyron is arguably the finest case history ever written in terms of its scope (duration of training and range of behaviors trained) and in terms of the full natural integration of training and behavior analysis to maximize the subject's progress.

Victor was captured in the forest of Aveyron and

brought to Paris in 1800. Authorities, especially Pinel,






17


estimated his age to be about twelve years and diagnosed his condition as incurable idiocy (Lane, 1976). Victor initially created a professional and public sensation in Paris, but the excitement soon abated since the boy was filthy, unmanageable, and "differed from a plant only in that he had, in addition, the ability to move and utter cries" (Itard, 1806/1960, p. 54). Itard, however, was struck by Condillac's comment that earlier feral children seemed to possess the intelligence required by their environments. Based upon this observation and upon the works of Locke and Rousseau, Itard reasoned that Victor was largely a product of his environment and that "he had only to find the proper social and physical education in order to supply the mental content that would make the boy a normal human being" (Itard, 1806/1960, p. viii).

Realizing that the weight of current medical opinion

was against him, Itard requested and received permission to care for and train Victor. If the authorities were correct and Victor proved untrainable, Itard hoped to at least provide data to speak to the heredity vs. environment question. He surmised that,

someone who, carefully collecting the history
of so surprising a creature, would determine
what he is and would deduce from what he lacks the hitherto uncalculated sum of knowledge and ideas which man owes to his education. (Itard,
1806/1960, p. xxiii)

Itard completely, successfully fulfilled neither aim: Victor never became a "normal human being," nor did Itard find a definitive answer to the nature-nuture question. But









Victor did acquire a behavioral repertoire that far exceeded the predictions of Itard's contemporaries, and Itard did illuminate the role of the environment in shaping behavior. In so doing, Itard changed the course of education, particularly for disabled persons. He placed the emphasis of education upon the individual, letting his pupil's behavior determine the course of instruction at every step along the way. The business of education, he felt, was "detecting the organic and intellectual peculiarities of each individual and determining therefrom what education ought to do for him and what society can expect from him" (1806/1960, p. 50).

Itard's description of his work with Victor is fascinating and educational to the modern reader in a number of respects. Not the least of these is the way that itard repeatedly reasoned out and applied behavior management principles. For example, one of Victor's earliest pleasures was going out to eat in town. Itard immediately saw the value of establishing reliable cues for this event and using them to reinforce behavior:

I was careful to precede our expeditions by certain preparations he would notice; these
were to enter his room about four o'clock,
my hat- upon my head, his shirt folded in my
hand. These preparations soon came to be for
him the signal of departure. I scarcely
appeared before I was understood; he dressed himself hurriedly and followed me with much
evidence of satisfaction. I do not give
this fact as proof of a superior intelligence and there is not one who will not object that
the most ordinary dog will do at least as much. But in admitting this intellectual






19

equality one is obliged to acknowledge
a great change, and those who saw the Wild Boy of Aveyron at the time of his
arrival in Paris, know that he was very inferior on the score of discernment to
this most intelligent of our domestic
animals. (p. 23)

Itard was aware of and used a wide range of behavioral techniques, now labeled primary and secondary positive and negative reinforcement, fading, chaining, shaping, and punishment. He carefully observed the connection between his procedures and Victor's behavior, and was able to evaluate both his successes and failures. He was, for example, not surprised when his initial attempt to punish Victor's food stealing backfired:

In order to repress this natural propensity
towards thieving, I made use of chastisements applied during the very act. I
reaped what society generally does reap from terror of its corporal punishments,
namely, a modification of the vice rather
than a real correction of it. Victor
stole with cunning what until then he had
been content to steal openly. (p. 93)

Of all Itard's contributions, perhaps the greatest was

the way he used Victor's behavior to restructure continuously the training sequences. He invariably based a particular training procedure upon Victor's responses to earlier procedures. Into this scheme he skillfully incorporated true behavior analysis, teaching himself the laws of behavior and using the results of the analyses to remove obstacles to Victor's progress. While teaching Victor to match objects with pictures, for example, Itard realized that his original teaching device might well be inadequate: the pictures were





20


in a fixed order and Victor might thus be responding to the

order rather than to pictorial aspects of the stimuli:

To reassure myself I changed the respective
positions of the drawings and this time I saw him follow the original order in the
arrangement of the objects without any allowance for the transposition. As a matter of fact, nothing was easier than for him to
learn the new classification necessitated
by this change, but nothing more difficult than to make him reason it out. His memory
alone bore the burden of each arrangement.
I devoted myself then to the task of neutralizing in some way the assistance he
drew from it. I succeeded in fatiguing his memory by increasing the number of drawings
and the frequency of their transpositions.
I soon had material proof by experimenting with the transposition of the
drawings, which was followed on his part
by the methodical transposition of the
objects. (pp. 39-40)

Itard's documentation of the extensive changes he

produced in Victor thus stands as a model case history for

behavior analysis and behavior change. After five years of

work and despite some limits he could not exceed (e.g., he

failed in his numerous attempts to teach Victor to speak),

Itard had succeeded in transforming a savage into a civilized

adolescent. From his behavioral methods and his continuous,

informal analysis of the effects of his procedures came a

model for tra 4 ning the untrainable.


Claudia: Rationale for and Technical Aspects of the Case History


Rationale

There are several reasons for writing Claudia7s case

history. The work is intended to fill a gap in the literature





21


OfL behavioral analysis and behavior change. Itard wrote a treatment-oriented case history of still-unparalleled scope and detail. Modern behavior analysts and therapists have added precise, quantitative measurement, graphic displays and, occasionally, sophisticated scientific inquiry methods. The scope of these recent efforts has, however, been far more limited than Itard's. The present case history is a combination of these aspects. It is a case history of training and analysis spanning two and a half years and covering virtually every relevant aspect of the subject's life, with each training sequence and subsequence guided, evaluated, and documented by direct quantitative behavioral measurement. Its scope is necessarily more limited than that of Itard's undertaking; likewise, every procedure employed and response trained was not subjected to as intense an analysis as has been seen in the most analytic modern case histories, with an exception: One aspect of Claudia's training was a largely analytic endeavor-- the determination of her visual threshold. Since this activity's emphasis was more analytic than

treatment-oriented, the results are presented as a separate section.

Claudia's case history is the result of the juxtaposition of an individual in desparate need of intensive training and a federal grant, P. L. 89-313, that mandated such intensive training. The author was thus able to integrate direct behavioral measurement and formal and informal behavioral analysis techniques to do what he could to help Claudia.





22


Technical Aspects

As indicated earlier, all data reported herein were

recorded routinely as part of Clui' training. In this

sense, the measurement,.training, and analysis techniques used with Claudia were no different than those afforded the fifty-plus other clients trained by the STARS Program. Claudia merely received longer and more intense training than her peers, as she was the first client accepted into the program and her severe rumination necessitated extra training.

The data are primarily behavioral frequencies reported in responses per minute, with several exceptions, such as weight recordings.- The data were recorded by the author and by full-time STARS Program employees;~ all data collection procedures were monitored by the author and other supervisory STARS staff. With the exceptions of baseline and other "hands off" periods, data collection generally occurred during the actual training session-- trainers used responsecounters and stopwatches to record the behaviors in-session, rather than recording in pretest-posttest fashion. To maximize the accuracy and usefulness of the data, most responses recorded either produced "behavior products" (see Johnston & Pennypacker, in press) or else were discrete and unambiguous. The staff thus obtained accurate data with no disruption of the training sessions.

STARS data, including Claudia's, are generally recorded on the Standard Behavior Chart (Lindsley, 1968; Pennypacker,





23


Koenig, & Lindsley,.1972). Figure 1 is a typical chart from Claudia's training folder and represents the core of STARS record-keeping and training-progress procedures. The trainer conducting the session recorded the data both on the chart and in numeric form on a separate sheet. Supervisory staff checked the charts for accuracy on a monthly basis. Other records, such as attendance sheets and Sunland campus behavior checklists, were maintained, but the behavior charts account for the overwhelming majority of STARS client information. Figure 1 highlights conventions necessary to interpret the data reported in the following sections. The labels at the bott"-om of the chart are self-explanatory. Also note that data are recorded by calendar days, rather than by successive sessions; the advantages of displaying data against a real time dimension are well-document~ed elsewhere (see Pennypacker & Johnston, in press). The primary data are response frequencies, in responses per minute. Dots (.) generally represent correct or appropriate responses, the frequency of which trainers attempted to increase. "X's" generally represent incorrect or inappropriate responses, targeted for decrease. Exceptions are noted when relevant. Dashes (-) are "record floors" and denote the reciprocal of the amount of time during which data were collected. Frequencies of 0 are noted by placing the data point directly below the record floor. Since the frequency scale (ordinate) is logarithmic, the combination Of frequency and record floors preserve the entire record-the distance on the log scale between the record floor and the 1/minute frequency line is the recording time in minutes;





24
















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25


the distance between the record floor and its corresponding behavioral frequency is the response-count. "Phase lines," the vertical bars between sets of frequencies, denote changes in procedure or other environmental changes.

The charts in the case history have been slightly

modified for greater clarity. Horizontal (days) and vertical (frequency) axes are identical to those on the Standard Behavior Chart, but the grid has been removed. All charts have been reduced to conform to editorial requirements. The charts are otherwise identical to those used and updated daily in routine client-training operations.














CHAPTER 1I
CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR
ANALYSIS AND BEHAVIOR CHANGE


Background: Claudia's First Seventeen Years'


From Home to the Institution

Claudia was born in Jacksonville,,Florida, in November, 1958, a healthy seven pounds, three ounces. Her mother had had phlebitis during the pregnancy, but no other complications or diseases were noted. There was no family history of retardation.

At age two months, Claudia appeared to be allergic to milk, but was otherwise healthy. Her parents began to worry at three months: she was still'healthy but seemed to be hyperactive and they noticed that her eyes were divergent and her tongue abnormally large. A month later, the doctor noted delayed bone development, but it was not consistent with cretinism. Her waking EEG was normal and several tests for PKU produced negative results.

The parents continued to be upset. During the following several months they observed that Claudia neither reached for objects nor held her bottle. She did seem to notice people


lThe information in this section was culled from administrative,' medical, and cottage records. Details of Claudia's early training are sketchy and unreliable; hence, only the barest facts are presented here.

26





27


and things and laughed when her parents played with her, but she did not "socialize" very often. Her movements were jerky and the large tongue was continuously out.

At seven months, the parents insisted on a diagnosis. Neither PKU nor cretinism was the problem, responded the doctor, but Claudia was probably retarded. She was developing slowly, but not excessively so.

Several months passed, and doctor and parents realized

the child was definitely retarded. They applied for Claudia's admission to one of the Suniands, Florida's retardation institutions. The Sunlands were full, and Claudia was put on a waiting list. Eight months later she was re-evaluated and considered for placement at either the Gainesville or Orlando Sunland. Although she could walk only with complete support, Gainesville was the appropriate site: the doctor felt she would be walking unassisted within three years, and openings at the Orlando Sunland were reserved for cases with more severe ambulation problems.

In 1960, at age eighteen months, Claudia became one of

the many "retardation, cause unknown" residents of Gainesville Sunland.


Life at Sunland

There is no record of formal training provided for

Claudia during the next thirteen years. This is not surprising. The institution was overcrowded and woefully underfunded. Maintaining basic living requirements for the residents






28


devoured most of the bud( et7 the remaining training monies had to be spent on the highest level residents, those able to benefit from extant teaching and therapy technologies. For the lower functioning residents, including Claudia, little could be done; even had training funds been available, these residents appeared to be untrainable.

Claudia was definitely, as the higher level clients put it, a "low grade." Her mental age at admission was six months, I.Q. 32; four years later she tested at mental age 7.4 months, I.Q. 9 (Cattell Intelligence Tests). Subsequent attempts to test her using the Stanford-Binet were recorded as "IFTI" (formal testing impossible), and she was classified at the lowest level on the Adaptive Behavior Scale. In short, she was growing older but developing no new behaviors.

In 1973 she was re-diagnosed as Down's Syndrome. The diagnosis was only temporary-- tests revealed that her chromosomes were normal. Unbeknownst to her, she was again "profoundly retarded, cause unknown."

That same year, reports of self-injurious behaviors appeared in Claudia's records. None of the behaviors-chewing fingers and toes, occasional head banging, and rumination (regurgitating and reswallowing food)-- were present when she was admitted to Sunland. There is no clue as to how or why the behaviors emerged.

Shortly thereafter, some formal programming began.

Her records state that she was being trained in "self-help skills,"~ but there is no account of the regularity, intensity,





29


or nature of the training. 'No skills development was recorded.

During the same period, Claudia was assigned a foster

grandparent, Julia. The foster grandparent program provides elderly people a small supplemental income and was designed to give the lowest level clients personal attention and a chance to get outdoors for several hours each day. Although structured training is not necessarily part of the program, a grandparent is often a client's only source of special attention. Julia thus became a major figure in Claudia's life, appearing five days a week to take Claudia out of her cottage in a wheelchair to tour the grounds or sit in the sun.

in 1974, a physical therapist examined Claudia, now 15.

She had never learned to walk, nor could she learn: both feet were severely turned down and inward at the ankle. She had learned instead to "scoot,11 as many clients do; sitting upright, she pulled herself forward with her feet, pushing with her hands. She was admitted to the hospItal for corrective surgery. The triple arthrodesis operation was performed without complications, and Claudia returned from the hospital physically capable of walking. But she did not walk. There was no one to teach her.

A year later, in July, 1975, Claudia fractured her left

tibia. She was placed in the hospital., and there she remained for several months so that the fracture could heal. During her stay in the hospital, her rumination drastically increased. When she returned to Lilac Cottage in November, she weighed forty-nine pounds down from her previous high of seventy-three.





30


This was Claudia as 1975 drew to a close. She was seventeen, fifty-six inches tall and weighed forty-nine pounds. Unable to walk, talk, or in any way care for herself, she had developed no new behaviors during her fifteen and a half years at Sunland, except, of course, chewing her fingers and toes, banging her head, and ruminating; the last was slowly killing her by malnutrition.


The STARS Meet Claudia


The STARS Program at Lilac Cottage

In late 1975, federal funds were released to open a new training program at Sunland. Six of us were hired to create the "behavior modification component" of grant PL 89-313. Our grant specifications were flexible; we were to build a staff of seventeen to work on an individual basis with no more than thirty-five profoundly retarded clients under twenty-two years of age. Training was to occur in the areas of motor, self-care, and social skills; that is, we were to be behavioral jacks-of-all-trades.

our supervisor selected Lilac Cottage as the training site (Fig. 2). It contained girls' and boys' wings and was reputed to have the campus' highest proportion of appropriately-aged "untrainables"-- multiply handicapped, aggressive,, and self-abusive clients who needed individual, intense training that other programs could not provide. Funds to hire the remainder of our staff were temporarily "frozen" and money to open our training building was not yet released;' *so






31





























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a week before Christmas we opened our office in the ladies lounge at Lilac and went to meet our young charges.

Going first to the girls' wing we discovered that the

stereotype of institutions was perhaps not just a stereotype. The doors were locked to prevent ambulatory clients from running or wandering away. Within, we found drab concreteblock-and-tile walls and bare floors; no bright colors or decorations or toys relieved the monotony. As much as the physical layout was typically institutional, the clients were even moreso: thirty girls, most of them lying or crawling on the floor, several who were ambulatory wandering aimlessly or coming up to grab at us. All of them were dressed in ragged clothes or ripped gowns. Clothing was for shredding and toys for breaking-- any free object was for mouthing and eating. We had tried to choose a population in need of training. Clearly, we had chosen correctly.

Since there were thirty girls, and twenty-five boys in the other wing, and our enrollment limit was thirty-five, our first task was forming a list of priority clients. Test scores and profiles were of limited value as the clients ranged from low-I.Q. to untestable and most were labeled profoundly retarded. The most obvious way to begin our list was to ask those who best knew the clients-- the cottage parents, or residential care staff, whose job was to bathe, diaper, dress, feed and otherwise care for the clients.

They laughed at our first request. All the children

needed anything we could give them. But yes, there was one





33


girl about whom they were especially concerned. Claudia had been ruminating more than ever, and they were worried about her.

They pointed her out to us. From a distance she was

not remarkable, one of the smaller figures in white, laying on her back with knees tucked up about her chest. Walking over and sitting down beside her, we understood the cottage parents' concern. Her knees were huge compared to her toothpick legs, her arms were skinnier still, and her ribs showed clearly through where her gown was ripped. She had shoved about six inches of a diaper into her mouth and periodically made a small gagging noise, following which a milky vomitus appeared in her mouth. Half the substance ran down her chin onto the diaper and gown; she manipulated the remainder with her large tongue, turning it over while chewing on the diaper. After about twenty seconds, she swallowed and repeated the process.

It was difficult to determine whether Claudia was

attending to us. Her eyes diverged and we couldn't ascertain where or if she was focusing. In any case, she made no attempt to reach for us and altered neither her position nor her ruminating routine. She evidenced no awareness of our presence.

We examined the remainder of our potential clients and retreated to our office to begin building our program.





34

Initial Observations

We six were young, fresh", eager-- and naive-- and in no

mood to await a "go" signal from the state. We had no budget, nor could we hire trainers, but we could prepare our recordkeeping systems, programming procedures, and the like. And we could get to know our kids.

Although there was a campus cafeteria, the residents of Lilac and other locked cottages did not attend. Food was delivered by truck to these cottages. The cottage parents dished it and took it on carts to the living wings. At meal time, we went to the wings and helped feed the clients. We discovered which clients possessed which skills, learned to diaper them, played with them, and wondered about the job we were taking on.

We also knew at least one client with whom we would be

working, and obtaining a baseline record of Claudia's rumination became our first official project. Designing the data collection and recording procedures became my responsibility.

My first activity was to observe Claudia's feeding procedure and get a closer look at her rumination. The feeding routine rarely varied. Claudia's diet consisted entirely of "blend," or pureed vegetables, meat, etc., and Sustacal. Blend was given to clients who didn't chew, and the Sustacal, a nutrient-rich milkshake-like liquid, was prescribed for Claudia to combat her rumination-induced weight loss. When the food cart arrived at the wing, a cottage parent would feed Claudia in whatever position she





35


was to be found, usually onher back on the floor. The blend was served in twelve ounce bowls and the cottage parents fed it to her in a tablespoon as fast as she could swallow it, about one swallow every 'Live seconds. Following the blend, the cottage parent sat her up and fed her a cup of Sustacal, which she eagerly accepted. Although she wrapped her hands around the cup, she needed help in holding it and had to be slowed down-- left to her own devices, she would open her mouth wide and turn the cup upside down, spilling most of the liquid. The entire procedure took less than five minutes. As the cottage parent moved on to feed another child, Claudia commenced ruminating. After watching the procedure for several meals, I began feeding her. I was uncomfortable feeding her at her accustomed rate, but this was my first baseline and I didn't want to disrupt it, and Claudia certainly didn't object.

During these meals, I was happily forced to correct an

initial impression. The girl was not entirely unaware of her surroundings. True, most of the time she attended to nothing, but when the food cart arrived, she looked toward the door. Upon spotting the cart, she balled up her hands and rubbed her eyes and nose, making excited gurgling noises. If she was not first to be fed, she scooted over to the cart, looked up at it and continued her noisemaking until it was her turn to eat. If and when we could control the rumination, we obviously had a powerful reinforcer for other training.





36


I soon discovered that food was not the only thing that commanded Claudia's attention Monday through Friday, at ten o'clock, the foster grannies arrived. Claudia looked as they entered the cottage, and she was clearly able to discriminate her granny, Julia. The hands balled up and she rubbed her eyes and nose; she watched closely as Julia collec-Ced a sweater and wheelchair for the daily outing. Once in the wheelchair and out the door, Claudia calmed down again, ruminating and attending to little around her. But at least we were certain that she enjoyed leaving the cottage and that she could discriminate the source of this pleasure.

Watching Claudia ruminate as she went out with Julia

piqued my curiosity. She seemed to enjoy going out, and it was her only break from Lilac, yet the ruminating continued. Before beginning systematic data collection, I couldn't resist playing a little, trying to find an activity that would reduce the rumination. I talked to her and, poor thing, sang to her, sat her up and played with her hands, but without result. I stood her up and walked her around the cottage. She was capable of walking with complete physical assistance, bu-LL- she ruminated as well standing as she did on her back. The cottage parents said she liked balls but had no chance to play with them as they were among the other clients' favorite objects to tear and eat. I produced a ball and she became excited, bouncing it and even attempting to keep other clients from grabbing it. Here was yet another poten tial reinforcer and further evidence of intelligence and motor





37


control,,but still no help for the problem at hand. Ruminating and bouncing the ball were not at all incompatible.

So much for clever ideas. It was time to quantify the

problem and explore it carefully. But we had learned much from these first encounters. Claudia responded to things and people around her. Perhaps eventually we could do more than try to stop the rumination.


Rumination Baseline

We were in a hurry and wanted to do everything at once. We had arrived at Lilac two days earlier and were simultaneously trying to get acquainted with our clients, develop assessments, set office policies, and wrest our grant money and training positions from the state. Now Claudia had caught our attention. We needed to collect the data necessary to make our first training decisions without disrupting our grant start-up activities.

As we had neither staff nor time to continuously monitor Claudia, we chose a sampling scheme. At breakfast and lunch one of us fed her in the usual manner. Immediately after the meal, the staff member stood back and counted the ruminations for five minutes. A staffer returned for five minutes each half hour thereafter until no ruminations were observed in two successive samples. The ruminations were easy to count, as the gagging noise was clear, the vomitus easily visible, and chewing was pronounced following each response.

The rumination followed a regular pattern (Figure 3a).

Immediately after eating, Claudia ruminated about three times







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39


per minute and did so for about an hour. Thereafter, the frequency gradually decreased, tapering off to near-zero three to four hours after the meal.

We knew that actual training could not begin until well after Christmas. We had yet to hire our staff and once

hired, they had to endure two weeks of orientation and inservice work. We also knew that Claudia was a heavy ruminator-- her physical condition well attested to it-- and we could see no sense in belaboring the obvious by collecting weeks of "uncontaminated" baseline. We couldn't train Claudia but we could manipulate her diet and observe the effects on rumination frequency.

The Sustacal was a likely place to start. Although the doctors had prescribed it to keep her alive, we were struck by the similar appearance and viscosity of the nutriment and the ruminative vomitus. In the ensuing weeks we fed Claudia her blend and Sustacal separately; blend an hour before Sustacal (Figure 3b), Sustacal a half hour before blend (Figure 3c), and no 'Sustacal until food-induced ruminating had ceased (Figure 3d). We returned to the original baseline condition and took stock (Figure 3e). Although the data were not convincing, Sustacal seemed to induce more rumination than did the blend.

We called the rounds nurse and obtained permission to replace the Sustacal with water and jello for several days. We were encouraged by the result (Figure 3f). Ruminating after blend continued, but the water and jello, given an





40


hour previously induced little rumination, Fearing the consequences of removing the extra nourishment from Claudia's diet, we returned to our original baseline condition and began planning training procedures. Wehad never succeeded in decreasing the overall rumination freq uency below one per two minutes (Figure 4), but we had demonstrated to ourselves that we could induce behavior change in our clients. It was a heartening fact to those of us new to the field. Designing the Rumination Procedure

While we were manipulating Claudia's diet, the state released our training positions. We hired our staff and arranged our schedule. Since decreasing self-abusive behaviors was to be a training priority, we devised staggered shifts covering twelve hours per day, seven days per week. In this way, clients chosen for intensive training could be monitored during most of their waking hours, including all meal times, and there would be no need to base training decisions upon small behavioral samples. Claudia and Tammy, a girl who had pulled outmost of her hair and slapped her face severely, were to be the clients to receive twelve-hourdaily training.

As we awaited our trainers' return from their orientation activities, we assessed the results of Claudia's baseline and considered possible procedures for decreasing the rumination. We wanted first to restructure the mealtime environment. Even though Claudia had demonstrated that she would ruminate







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wherever she found herself,:we thought that 4 more closely controlled setting than the floor of the cottage day room would foster more effective intervention. Our program owned several pieces of equipment purchased with early grant funds. One of the purchases was a small wooden relaxation chair commonly used by physical therapists. It was perfectly suited to our needs. The adjustable head rest and clip-on tray would allow us to feed Claudia in an upright position and would restrict her movements without discomfort. We could watch her closely for post-meal rumination. The apparatus was mounted on wheels, giving us the option of feeding her in the bedroom area or hall, away from her usual location without having to drag her into and out of a wheelchair.

We also agreed that it would be wise to slow down her eating. Most of the clients ate rapidly, .whether feeding themselves or fed by the cottage parents; the fast eating did not seem to induce rumination. Still, Claudia did not ruminate while she ate and perhaps increasing the duration of the meal and decreasing the rate of food intake might help slow the rumination. We watched one another in the campus cafeteria and concluded that one bite per fifteen seconds was a reasonable rate.

The Sustacal posed a tricky problem. Our data suggested that Claudia ruminated less without it, yet it constituted a major portion of her nourishment and possibly was keeping her alive. While we pondered the medical and financial





43



feasibility of various powdered food additives, one of the cottage parents offered a far simpler solution. Why not mash peanut butter and jelly sandwiches into the blend? The result might not be esthetically pleasing, but neither was the blend alone, and Claudia was hardly a gourmet. The peanut butter was rich in protein, the whole sandwich might put weight on her, and the thick, gooey product certainly looked harder to ruminate than did Sustacal. The rounds nurse readily granted approval. We could eliminate the Sustacal, replacing it with our concoction. Water and jello before the meal would ensure adequate liquid intake. We would be alerted to any problems arising from the new diet, as we had been weighing Claudia almost daily since data collection had begun.

We were not satisfied. our planned procedure would

probably reduce the rumination but almost certainly not stop it. We could foresee a temporary decrease in the rumination frequency, followed by a gradual increase as Claudia adjusted to her new diet and feeding environment. Any other training we might try would be hampered by and possibly enhance the rumination. We therefore sought assistance from published cases of rumination treatment.

We located two strategies, response-contingent electric shock (Lang & Melamed, 1969) and response-contingent squirts of lemon juice (Sajwaj, Libet, and Agras, 1974). Shock was out of the question. No one had ever systematically tried to stop Claudia's rumination, and to begin with such a painful procedure would be irresponsible ard unfair to Claudia. In





44


addition, Florida's retardation system operated under a set of behavior management guidelines that clearly forbade the use of shock.

Using lemon juice was feasible. A trainer could use a laboratory wash bottle to squirt a small amount, one cc or less, onto Claudia's tongue each time she attempted to ruminate. The attempts were easy to spot. The gagging noise reliably preceded each appearance of the vomitus and we could thus "catch her in the act," increasing the likelihood of our success.

Our final preparatory step was to present our baseline

data and planned procedures to the campus behavior management committee. At the time, even using lemon juice was of questionable status in the behavior management guidelines and required the approval of campus administrators and consulting professionals. moreover, behavior modification was a newcomer to the campus and Its practitioners were closely monitored. Permission was granted and we were ready to begin.

Several years later, a colleague asked me why-- after I had independently assessed at least several elements of our procedures during those first weeks-- I chose a "kitchen sink" treatment. The relaxation chair, the spaced feeding, the diet changes, the lemon juice, all at once; it was hardly a systematic approach to the problem. Granted, it was not, But it was our program's first project and we were testing our competency as behavior change agents. For the Sunland campus, it was a test of a new kind of training





45


intense,,i.ndi.vidualized,.and based directly upon behavioral data. Most importantly, it was our chance"to help Claudia. She did not know us; we had done little except observe her rumination. But we were getting to know her and wanted to help. We planned to use every tool at our disposal to do so.


Training Begins


Results of the Rumination Procedure

On February 5th, Claudia ate her breakfast as she

usually did, on the day room floor. She spent the morning ruminating while Marsha-- the trainer I assigned to Claudia-and I passed the time fretting, pacing and reviewing procedural details. At lunch time, Marsha brought in the relaxation chair. We seated Claudia and wheeled her into the bedroom area. Marsha placed herself opposite Claudia and arranged response counters, stop watch, the gooey mess that was lunch, and the wash bottle of lemon juice. The feeding went smoothly and we even observed an extra benefit. The sticky peanut butter, harder to swallow than blend, helped pace the food intake. Claudia was hardly fazed by our tension and the new setting and diet. Soon after lunch we heard the first gag. Marsha was ready and delivered the lemon juice accompanied by a stern, "No, Claudia!" The intervention startled Claudia and she jerked her head away. She ruminated again, and again Marsha was ready. The attempts to ruminate dropped abruptly and within an hour we were able to take her out of the relaxation chair. We seated her in the cottage





46


lobby to watch her and be ready with the lemon juice until we were'sure ruminating had ceased for theafternoon.

At dinner we repeated the procedure and were again

successful. Claudia had begun the day ruminating at her usual rate of one to two per minute. With our procedure in place,. the rate dropped to about one in seven minutes, an eightfold decrease. We went home that night elated but concerned. Would the effect last or was it merely due to the novelty of the procedural barrage?

The next day indicated that it was not. The ruminating rate remained low. After breakfast, trainer and lemon juice accompanied Claudia and Julia on their daily excursion. Julia had watched Claudia vomiting herself to death and had helped us during baseline data collection. She and the other foster grandparents shared our excitement.

On the third day, the ruminating rate declined to one in twenty minutes; by the fourth day it was one in fifty. Within a week, Claudia had gained five pounds and was ruminating at one one-hundredth her original rate. The rate stabilized (Figures 5, 6a). Within two months we were able to give her her liquid after meals, with no increase in rumination.

With the rumination under control, Susan, Claudia's

morning trainer, decided to find out what Claudia liked to eat. We had purchased a variety of candy and snacks for the clients and Claudia was entitled to he-- share. I arrived at work one morning to find Susan upset. If Claudia had to put up with the unsightly blend because she couldn't chew, why was







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she so adeiDt at crunching potato chips? I didn't know. Neither did the medical staff,,so we. replaced the blend with regular meals, still supplemented by peanut butter and jelly.

Claudia continued to gain weight (Figure 6b). During

the next several months, we eliminated the peanut butter and jelly sandwiches one meal at a time. Much later, we had to put her on a diet and remove fattening desserts. We looked back at the early weight records and laughed. Building New Behaviors I: Eye Contact

In our concern over her rumination, we had given little thought to what we might teach Claudia. Several days had passed since we had begun rumination intervention and her trainers now had little to do but watch her. We did not dare return her unattended to the cottage day room for fear the rumination would regain its previous rate. Claudia possessed a limited behavioral repertoire and by reducing the rumination we had left her with almost nothing. Where to start building?

"Attention span" was a logical prerequisite for training. Eye contact with the trainer was widely regarded as the first step in establishing visual attending behavior (Kozloff, 1973; Foxx, 1977). In addition, it seemed that recognizing one's name was a necessary, basic skill, one that Claudia did not possess. We had never seen her respond to her name or to anyone's voice. Only loud noises and the sound of the cottage door and rolling food cart seemed to attract her attention.






50

We resolved to teach her to look at us when we called her name.

To ascertain that she did not, in fact, know her name, we began with a baseline procedure while she sat in her relaxation chair before meals. When Marsha was sure that Claudia was not looking at her, she would say, "Claudia, look at me" and record whether Claudia's eyes met her own within five seconds. Marsha continued in this manner for five weeks, about two minutes per session, and obtained relative frequencies of looking and not looking. During the first three weeks, Claudia rarely responded. Over the next two weeks, she began to make eye contact more frequently, but during only one session did she respond appropriately more often than not (Figure 7, phase A).

We reasoned that if we continued in this way, Claudia might eventually learn to respond consistently to Marsha's voice. However, we wished to teach her more rapidly. We required Claudia to earn part of her meal by making eye contact. The procedure was similar to the previous one, except that it occurred during the first part of the meal. Marsha timed and counted the eye contacts, giving Claudia a spoonful of food on a continuous (CRF) schedule, one spoonful for each success. After Claudia had earned twenty spoonfuls, Marsha 'Led her the remainder of the meal. We had observed previously that Claudia's eyes invariably followed the spoon during feeding. We used this finding to institute a "fading" procedure (e.g., Whaley & Malott, 1968; Bassinger et al., 1971): Marsha began the training with the spoon







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directly in front of her eyes and over the next two and a half weeks gradually lowered it to plate level ("faded out" the spoon) while maintaining eye contact (Figure 7, phases B, C). After four and a half weeks the behavior was stable, but how long it had taken to teach such a simple response! Hank, my graduate advisor, was visiting one afternoon when Claudia was missing more responses than usual. I told him that I knew retardation training would be slow and painstaking, but until now I hadn't understood the definition of "slow." It was only the beginning.

We had achieved some measure of control over the eye contact at mealtimes, and extending this skill to other situations seemed imperative. We must continue to use food to reinforce the behavior, that much was clear, but extra feeding between meals might increase the rumination. we opted for small bits of food, marshmallows and raisins, and conducted the session about an hour before meals. The effect was immediate. We lost our hard-won gains (Figure 7, phase D). Was it the change in session time, or was it the marshmallows and raisins? When she discovered Claudia could chew, Susan had observed that Claudia would eat almost anything but was more excited by her meals than by the snacks. We replaced the marshmallows and raisins with small spoonfuls of blend and regained control of the eye contact (Figure 7, phase E). We had lost control of the eye contact for a week, but our data were instructive: Candy has been widely used as a reinforcer, but our chart indicated that it would not





53


reinforce Claudials.behaVior. It was nice to know that she preferred nutritious substances to junk food, a finding that maintained throughout her training.

We varied position and distance of the trainer relative to Claudia, and began rewarding the eye contact with blend on a variable ratio (VR) 2 schedule, about one spoonful for each two appropriate responses (Figure 7, phases F, G). At the end of the project, Claudia always raised her eyes when we asked her to look at us.

But we had failed in several respects. First, we did

not teach "eye contact" with emphasis upon "contact." It was clear that Claudia was not looking at us. Rather, she had developed a cute, stereotyped response, eyes raised to about the level of our eyes, gaze fixed, mouth slightly open to receive the food, head cocked to one side. The fixed gaze sometimes a shade above or below our eyes, let us know that she was not really looking at us. Second, she had not learned her name, nor did she respond to our voices except in a training situation, with spoon present. We could have continued the project, gradually increasing the ratio of responses to food, but to what avail? We couldn't modify the stereotyped responses.

We gained much from this project, though. We had built a behavior, even if not exactly the one we had intended, where there was none before. Claudia could learn new skills. we also learned that "attention," or at least attention as we viewed it,.was not a necessary first step in training. Her





54


progress in other areas without -it would subsequently confirm that fact. She did begin to respond to her name and to really look at us, much later, as a by-product of the thousands of hours we worked with her. The "basic skills" turned out to be complex achievements.

Claudia has never lost this first response she learned. Over the following two years the response would appear again, when we were trying to teach her new skills and having trouble. She would frequently raise her eyes and assume her old expression, as if following the rule, "when all else fails, try eye contact." That facial expression became dear to us.


Building New Behaviors II: Playing Catch

After meals, Claudia's trainers generally gave her a

soccer or large plastic ball to bounce while they monitored the rumination. She entertained herself this way for hours. When her trainer brought out the ball immediately after the meal, she grew excited. If the trainer bounced the ball before giving it to her, she frequently bounced in her seat while watching. But once she was given the ball, she rarely returned it.

We saw here an opportunity to interact with Claudia

in a purely social manner. Teaching her to play catch might also give her a skill she could use on the cottage with other clients. And it was our first opportunity to play with this girl who knew us only because we fed her and scolded her when she ruminated.





55


Her trainers tossed her the ball from about four feet away, clapping their hands-and telling her to throw it. If she threw or bounced it back, the trainers counted a correct response. If she threw the ball in the wrong direction or failed to throw it at all within ten seconds, the trainer retrieved it and tried again, counting an inappropriate response. When we started, she returned the ball to us about half the time. In only four weeks, we all but eliminated the correct responses (Figure 8, phase A). Most of the time she threw it in the wrong direction, frequently over her shoulder. Perhaps she was responding to terminate the game or to watch us chase the ball. Either way, this was not our idea of a good time.

We reviewed the situation and made note of the following: First! we were sure that playing with the ball was a reinforcer. Before we had begun the catch program, Claudia reliably grew excited upon presentation of the ball and quickly retrieved it if it rolled away from her. She played with it for seemingly endless periods of time; this was a high-rate behavior and therefore a potential reinforcer (Premack, 1965). Second, we recalled the well-established findings that satiation decreases the effectiveness of reinforcers and deprivation increases reinforces' effectiveness. Prior to our interaction with Claudia, she rarely had access to balls; she now had access to them for several hours per day in addition to the catch-program time. We might well be observing the effect of satiation. If so, we would do well





56


to create instead a state of deprivation by limiting her access to the ball. Finally, we*analyzdd the consequences we had arranged for the game of catch. When Claudia responded correctly by throwing the ball to us, we threw it back, continuing her access to the reinforcer. However, inappropriate throws resulted in almost the same consequence-- we retrieved the ball and threw it to her again. A widely-used, highly successful method of reducing inappropriate behavior is time-out, the brief withdrawal of a reinforcer contingent upon the undesired response. Perhaps such an arrangement-briefly limiting access to the ball after incorrect throws-would he an effective consequence.

Based on our analysis, we changed the rules of the game so that she would play our way or not at all. We only gave her access to the ball during sessions. If she threw it in the wrong direction we stopped the game for two minutes (the stopwatch did not run during this time). If she threw it in the wrong direction twice in succession, we terminated the game and did not play again until after her next meal.

it was hard to enforce the new rules. We were growing

fond of Claudia and playing with the ball was the only thing, except eating and going out with Julia, she liked to do. We did not like to take away the ball, but we were determined to teach her to play with others. Most of her fellow clients seemed to enjoy our attention, and we were spending more time with Claudia. Besides, we didn't enjoy chasing the ball around the cottage.'






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Wehung on and slowly, imperceptibly, she began to play (Figure 8,phase B). After eleven weeks we terminated the procedure, or rather she terminated it. She would throw the ball as long as anyone was willing to play with her and she wore out trainer after trainer. We gave her free access to the ball again and the choice was hers. If she wanted to play, we'd play, but we were grateful for the rest when she bounced the ball by herself.

Trainers who have resigned return to visit the program and usually play catch with Claudia. It's easy to buy her a present she will appreciate, and she owns a truly impressive assortment of balls.


By-Products of the Early Training

Claudia's success in her new programs bolstered our confidence. We had begun the eye contact and ball-toss sessions simultaneously, within a week after starting the rumination intervention. The rumination rate remained low while Claudia acquired her new skills. Most of our staff worked with Claudia at one time or another, and we were all excited and proud.

But in early spring, the staff had some bad news for Marsha, Georgianne, and me, the people responsible for her training. "Your baby," they told us, "is spoiled rotten." We couldn't deny it. Before training began, Claudia had lain passively on the day room floor, growing excited only when Julia or the food cart arrived. Now there were occasional tantrums if her trainer arrived late for her meals. She would





59


cry and rock forward, sometimes banging her head on the floor. We were not worried about these tantrums, they seldom happened and the head banging occurred only rarely. Usually, she merely rocked, her' forehead stopping inches from the floor. occasionally she hit it and looked at us, commencing to cry. At least she knows us, we thought. The tantrums did not become a problem. We generally arrived before the food, and if a tantrum was in progress we did not begin her

session until she was quiet.

A more pressing problem was after-meal tantrums. We were still keeping her in the relaxation chair for a brief period following each meal, the crucial time for rumination. We were reducing this chair time, but evidently not fast enough for Claudia. She began screaming and crying, jerking around in the chair. We did not want to take her out once she started crying and risk teaching her to misbehave. Neither could we use an "extinction" method, that is, simply ignore Claudia until the tantrum ceased. Her behavior was more violent in the chair than during premeal tantrums and we were afraid that if we ignored her, she'd hurt herself while destroying the chair.

We simply could not let the tantrums begin. I took advantage of the chair's mobility, rolling it up and down the hall soon after she finished her meal. I could keep a cloae eye on her in case of rumination and she seemed to enjoy the ride; she gave me one of her rare smiles. I pulled a little faster, she smiled more. The weather was turning






60


pleasant, so I rolled her out of the cottage and we went tearing up and down the sidewalk. She laughed long and hard,

and won our hearts.


Basic 'Self-Feeding Skills


By early April we had a name for our program, STARS

(for Start.Training Appropriate Responses to Stimuli), a new training building, and a budget. It was spring and a time for change.

Marsha, George, and I grew more ambitious with Claudia's training. She had shown herself capable of at least simple skills, given time, patience, and careful monitoring by those who worked with her. Virtually everything had to be done for her and we wished to help her acquire more independence. The two areas that appeared to offer the best beginning were feeding and ambulation. Although her movements were jerky, Claudia was not spastic, so independent feeding did not seem an unreasonable goal. The triple arthrodesis operation several years earlier had left her physically capable of walking. We tackled both problems at once.


Learning to Scoop

Teaching Claudia to feed herself was perhaps the most initially promising and eventually frustrating project we attempted. She acquired the basic skill, independent scooping, more rapidly than anything else we taught her. Polishing the basic behavior and adding related skills was






61


an incredibly slow process and we met with failure more than once.

We began, of course, in the relaxation chair at mealtime. The chair was as ideal for teaching feeding as it was for monitoring the rumination. She sat straight and the clip-on tray was at a comfortable height. As much as she loved to eat, weknew she would be highly motivated to learn this new skill.

She had no trouble holding a teaspoon loosely in her fist, but we were unable to induce her to hold it as one usually does, between the index and third fingers with thumb on top. However, we had observed many clients feeding themselves using a fist-grip. It was more awkward than a normal grip but it seemed to get the job done. We considered ourselves to be lucky that Claudia held the spoon at all without prior training and we accepted the fist-grip. Her grasp was not strong, however; so we began the program with a built-up spoon, a commercially available product that has been successfully used to teach feeding skills to the profoundly retarded (Miller, Patton, and Henton, 1971). The handle of the spoon was a plastic cylinder three-quarters inch in diameter. This Claudia held firmly enough.

The procedure was simple. For the first few trials, Marsha wrapped her hand around Claudia's and.guided her through the entire motion, lowering the spoon, loading it with food, and raising it to her mouth. Marsha felt little resistance from Claudia's arm; the movement was smooth. and





62



natural. Marsha next released her hand and Claudia, with some difficulty, successfully loaded the spoon and fed herself. Claudia was awkward but persistent and Marsha did not intervene on a given scoop until it became clear that Claudia would not succeed on her own. When such was the case, Marsha took Claudia's hand and finished the scoop with her. Claudia was free to try alone on the next scoop. The first day, Claudia scooped without assistance in one of every four attempts. In little more than-a week she was scooping entirely independently. We allowed her to continue in this manner for several more weeks to gain proficiency. On the first day of training she had scooped independently at the rate of once per two minutes. Her speed rapidly increased to about eight scoops per minute (Figure 9, phase A),

Once again, Claudia had come through for us. For

seventeen and a half years she had been fed and within a few weeks was able to scoop on her own. It was so easy. We planned to put on the finishing touches, to teach her to use a regular spoon and to eat more neatly so that we could remove her bib. We were to be surprised and disappointed. Fine Details of Scooping

Although she was scooping rapidly and without assistance, Claudia was making a mess. She had added a new component to the scooping movement, rolling her wrist as she lifted the spoon to her mouth, taking it in upside down. Much of her diet was soft and sticky and adhered to the spoon, but the remainder landed on her bib, the tray, and the'floor.








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We had not intervened as the behavior developed since we did not wish to interfere"With her independent scoops.

We concentrated on the wrist rolling. Her grasp was

firmer now, and we replaced thebuilt-up spoon with a regular teaspoon, the handle of which we covered with friction tape to prevent slipping. We temporarily discontinued monitoring the unassisted scoops and began assisting her again, correcting position of spoon and wrist. We were not successful; we were unable to decrease the frequency of assistance (Figure 9, phase B). We also had to intervene in other ways. She was taking larger and larger spoonfuls. At one point, she lifted her entire portion of mashed potatoes and attempted to get them all in her mouth. She was as likely to scoop the food from her bib or the tray as she was from the plate. We began blocking the large and off-plate scoops, each block accompanied by an assist to initiate a correct scoop. We were unsuccessful again (phase C). At least, we consoled one another, she never attempted to use her fingers, even when struggling to scoop a small morsel from the corner of the plate.

We decided to begin afresh, to build a new scooping

movement. For several weeks we held her wrist on every scoop.. guiding her entirely through the motion. Then we gradually allowed her to scoop independently, increasing the frequency of unassisted scoops until they accounted for 75% of the

total (phase D) .






68


The frequency of large scoops was decreased and the

wrist-rolling was.gone.' Gone also was the tape on the spoon, worn off by repeated washing. Her grip was solid so we did not replace the tape. But now there was a new problem. She had begun scooping backhanded, shoving most of the food off the rear edge of the plate. We repeated our strategy, beginning with complete assistance and then allowing increasing numbers of independent scoops (phase E). Before she had even achieved one independent scoop per minute, her backhand returned. Again we assisted her entirely, then relaxed the assistance, and again she back-scooped (phase F).

we did not know what else to do. We considered several strategies and rejected them. Many more ideas, of course,, present themselves in hindsight. But we coped with the problem in our usual manner. We returned to complete physical assistance, this time for several months (Figure 9, phase G).

Many changes occurred during this period. Claudia began eating at the campus cafeteria as a result of her progress in other training sessions. The change in scenery did not help; occasional probes revealed that the backhanded scooping would reappear if given the chance. None of us could think of a way to modify the behavior.

In January, 1977, more out of frustration and discouragement than out of any change we observed in Claudia's behaVior, we changed the procedure. We allowed her to scoop independently, blocking and re-directing any attempted backhand scoops. She immediately regained her original independent






69


scooping rate of eight per minute. We had to assist her just over once per minuteand elected to wait and see what happened (Figure 9, phase H). Over the next seven months, the rate of assistance decreased to about once in five minutes, or several assists per meal.

We had, I suppose, succeeded. But the behavior change was small in relation to our expectations. We nevertheless continued to work on her feeding skills, meeting with success in some attempts and failure in others. Had Claudia not shown such remarkable progress in other areas, we would have been thoroughly discouraged.


Learning to Walk


While Claudia's progress in her feeding programs was

slow and often discouraging, helping her acquire ambulation skills rewarded us often. Progress was rapid at times and slow at others. The training frequently bogged down and was then revitalized by a sudden breakthrough. We had to face limits in some areas while in others she continued to grow. Teaching her to walk provided both the most challenging and gratifying experiences we had with her.

We had been considering teaching Claudia to walk from the time we began working with her rumination. She had undergone the operation to repair her feet,.giving her the physical capability to walk. Examining the conditions under which she ruminated, I had discovered that she would walk short distances if I held her hand tightly. However, the'






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rumination caused us to delay the start of formal walking. Wewanted first to bring the rumination under control and effect a weight gain, as we were afraid that her pathetic legs could not withstand any strain. While we waited, we began several preliminary programs to assess her current capabilities and to exercise her legs.


Preparatory Programs

The day after rumination intervention began, we started walking Claudia for a minute or two at a time, several times per day. Her trainers held her hands tightly but made no effort to force her to walk. She walked at a rate of fifty to eighty steps per minute, sitting down every fifteen to twenty seconds. Her steps were small, each covering about eight inches. They were not uncertain, clearly steps and not shuffles, but they were jerky and she swayed from side to side. This peculiar gait may have been due to the fact that she never developed hip rotation. The swaying mott--ion, while greatly reduced, has never disappeared and one can always spot Claudia walking, even at a distance.

For additional exercise we had her push an empty wheelchair. Her trainers walked behind her, keeping her hands firmly on the grips. She walked slightly faster with the wheelchair, between ninety and one hundred steps per minute. However, we abandoned the program within two weeks as keeping her hands on the chair was a problem and the trainers had trouble positioning themselves, leaning over her to maintain contact with her hands.





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Walking provided only several minutes of exercise each day and we did not feel that this was adequate. Although it was winter, it was frequently warm enough to go out during the afternoon, so we tried our luck with a tricycle. A trike would exercise her legs for about ten minutes at a time without straining her. Not her, perhaps, but it certainly strained us. Claudia would not keep her feet on the pedals. We tried built-up pedals, straps, and pedal stirrups, but with a wiggle or two of her feet she undid our best efforts. Several shoe laces tied end to end finally served the purpose. Enough loops and knots and twists and turns, and her feet remained firmly planted on the pedals. At first it took two of us, one to balanceher on the seat and one to perform the elaborate tying-on ritual. When she became accustomed to the trike, she helped by sitting still and only one trainer was necessary.

With her obviously limited tricycling experience, we

were not surprised to find that Claudia did not pedal. For three weeks we pushed her. The rotating pedals stretched and flexed her legs, giving them at least some exercise. In the middle of March, we noticed that we didn't have to push as often-- Claudia was doing some of the work too. we counted assists to move or steer, initially providing assistance almost six times per minute (Figure 10, phase A). Three weeks later, when we began her formal walking programs,, we were still assisting her at this rate, but there had been several days during which substantially fewer assists were necessary.








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The tricycle had served its original purpose in that it had given Claudia exercise preparatory to walking. But these first signs of success on the trike encouraged us to continue the program as an added form of recreation. We maintained the program only sporadically,,but Claudia slowly improved. At the end of July, we happily dispensed with the shoelaces, and she kept her feet on the pedals (Figure 10, phase B). A year and a half later, Claudia graduated to a bicycle With training wheels. She pedaled with nowhere near the proficiency required to eliminate the training wheels,,but we were satisfied. We had set out to give her exercise, and she had learned a new recreational skill in the process. The First Independent Steps

we began formal walking sessions in early April on the same day we began teaching Claudia to feed herself, and precisely two months after we began rumination intervention. She weighed sixty-six pounds, seventeen pounds more than when we met her, and we had observed no problems during her previous exercise programs. She seemed ready to walk alone.

We took her into the long hall that connects the girls' and boys' wings and let her sit on the floor. I sat beside her and showed her a cup with several sips of fruit juice in it. She became excited as she always did, rubbing her eyes and nose. I stood, walked back about eight feet, and stopped, always keeping the cup in plain view. She watched intently. From behind, Georgianne placed her hands in Claudia's armpits,





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lifted Claudia to a standing position, and walked her forward. About four feet in front of me, Georgianne let go. Claudia walked-- more precisely, staggered-- her first independent steps to my arms and her juice. We repeated the procedure and again she walked the last few steps alone. We were jubilant.

Then, caught up in the excitement of the moment, I erred badly. I wanted to see how far she would walk by herself. On the next attempt, I began walking backwards as she approached me, keeping about one and a half feet between us. She followed me for perhaps twenty feet, stopped abruptly, and sat down. I had pushed her too far. The sudden, drastic increase in the number of steps required for a sip of juice had probably extinguished the walking: Claudia had responded appropriately, I had failed to reinforce the behavior, and the walking disappeared. In such situations, merely requiring less work for each reinforcer is usually sufficient to reinstate the behavior (Reynolds, 1962; Krumboltz & Krumboltz, 1972).

We therefore tried again, only this time I had no intention of moving. A few independent steps would have satisfied me. None were forthcoming. As soon as Georgianne started to remove her hands from the armpits Claudia went down. Nine more attempts produced the same result. I was furious with myself. Weeks of preparation and planning, the sight of Claudia walking alone, and I had apparently negated all of it.





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This was also more than a little curious. Claudia had taken weeks to learn to make eye contact, and was not at the time even close to reliably throwing her hall back to her trainers. Yet I had pushed the walking just once and it disappeared. How could one who learned so slowly suddenly learn so fast? How could Claudia be so insensitive to some things in her environment and so sensitive to others? And why did her sensitivities seem to work against us? I did not know the answers then, nor do I now.

We did know, however, that the last time she had walked I was holding a cup of juice and was moving away from her. We tried again, but this time I did not hold the cup. We moved Claudia into the kitchen, I showed her the cup, placed it at the edge of a counter, and moved away. Georgianne lifted her as before, walked her toward the counter, and let go. Claudia covered the remaining three feet on her own and (with Georgianne's help) collected her well-deserved juice.

We continued in the kitchen for a week, ten to twenty

trials per day. We recorded the number of independent steps per trial and gradually increased the distance we re uired Claudia to walk by herself (Figure 11, phase A). We ran out of room when she reached eight steps per trial and moved back into the hall. We set up two small tables and substituted spoonfuls of blend for the juice. Georgianne left Claudia sitting at one table and placed the spoon on the other table. She returned to Claudia and helped her up, but it was no longer necessary to start walking with her; Claudia was able






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to begin each trial from a standing, stationary position. Claudia walked back and forth, receiving the blend and a brief rest at each table. We increased the distance day by day until she traversed the entire hall, seventy of her small steps (Figure 11, phase B).

At each end of the hall was a short passageway leading to the living wing doors. We moved the tables into these passageways, out of Claudia's sight. She was able to turn the corners and find her blend. During these sessions she never stopped and sat down before reaching the goal and her balance, while still not the best, improved.

While we were conducting these formal walking sessions, we also encouraged Claudia's trainers to give her extra, non-food-rewarded practice. The practice consisted of "graduated guidance" (Foxx & Azrin, 1973; Sundel & Sundel, 1975), having Claudia walk with as little assistance as possible. For example, after a meal, Claudia's trainer might walk her from the relaxation chair to the lounge, holding her wrists firmly at first, easing the pressure as she walked, and finally letting go. We counted her attempts to sit down during these short walks and discovered we were having no success (Figure 12). Although she attempted to sit down less frequently than she did before we began training, the rate'showed no further decrease as training progressed. We also realized that we were possibly working against ourselves by requiring her to walk without assistance in some situations while helping her in others.








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We abandoned the graduated guidance program and required her to walk short distances in the cottages by herself. When she sat down, which she did frequently, we helped her up but did not assist her in the walking. It was backbreaking work and occasionally took twenty minutes to cover the short distance from lobby to living wing. We didn't mind, for she was walking alone.


Rumination Redux


Unmonitored Rumination

Although we had expanded Claudia's training into many

areas, our primary concern remained the rumination. we monitored its frequency constantly as we added new training programs and it did not increase.

We calculated the rate based upon the amount of time Claudia spent with us, initially about ten hours per day. Several months into her training, I became curious to know how she fared when we were not present, from 7:00 p.m. until bedtime, about nine or ten o'clock. The cottage parents told me she was ruminating, though not nearly as often as she had previously. I stayed late one night to find out.

As the other trainers left for the evening, I handed my stopwatch to Betty, one of the cottage parents. I instructed her to start the watch. as soon as she heard me close and lock the door, and to turn it off the first time Claudia ruminated. She was then to bang on the plexiglass window in the door, signalling me to return. I left the living wing and had not





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yet seated myself in the office when Betty signaled. I returned to the wing and read the stopwatch, seven seconds. I had the washbottle of lemon juice in my pocket but did not remove it. Claudia and I stared at one another for a short time. I did not say or do anything as she did not ruminate again. I reset the watch, gave it back to Betty, and exited. I only walked far enough to be clear of the plexiglass window, knowing that I'd be wasting time to walk further. I was correct; the latency to ruminate was five seconds. This time, I had quite a bit to say to Claudia. It didn't- bother me that she couldn't discriminate her own name, let alone the content of my lecture about behavior management skills. It seemed as good a way as any to pass the time and see if she would ruminate in my presence. She did not, of course, and fifteen minutes later, Betty and I tried again. Each of the next three trials registered less than 15 seconds latency.

It is well-known that individuals in programs such as Claudia's~ programs designed to eliminate undesirable behavior-- quickly 'Learn when it is and is not "safe" to emit the target behavior (LJovaas & Simmons, 1969; Rollings, Baumeister, & Baumeister, 1977). Claudia's performance that night indicated that she had learned. I went home to ponder the problems of after-hours rumination.

Several days afterward, I stayed late again to work in the office. It was not hard to avoid the living wing and a rediscovery of Claudia's unmonitored rumination. However, I





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did not stop working until after 10:00 p.m. and 1 couldn't resist looking in to see our kids, so noisy and unmanageable by day, sleeping peacefully. Some clients slept, others were awake but relaxed, and Claudia lay comfortably curled up, ruminating.

I considered the alternatives. We could not extend our training schedule, and Claudia was already receiving more of our time than was any other client. Neither did I want to ask the cottage parents to intervene in the rumination. Two of them were responsible for showering the girls and putting them to bed, and I couldn't expect them to monitor and intervene consistently. Tn addition, the Florida behavior management guidelines, while unclear on the point, seemed to forbid such intervention by untrained personnel.

I therefore took no action and hoped for the best. The decision eventually proved correct. The nighttime ruminating gradually decreased, as verified by the cottage parents' reports and our periodic monitoring.


Procedural Revision

The first week in April, just before we began Claudia's walking program, I happened upon a fascinating occurrence in the boys' wing. one of the cottage parents was preparing to mop the floor after lunch when a client distracted her. As she tended to the boy, another client spied the open, unguarded closet. He rushed over, reached in, and removed an open bottle of detergent, which he began drinking with gusto. Several of us reached him simultaneously and grabbed the bottle





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before he had consumed verv much. No harm had been done and he laughed gleefully at our angry gestures and admonishments.

Here was I, convinced that the sour, concentrated lemon juice was controlling Claudia's rumination. The detergent certainly couldn't taste much better, but I had just seen a client consume it with apparent relish. The client was known for his pranks and he invariably laughed at our scoldings; the attention we paid him quite likely overrode the taste of the detergent. Perhaps it was not the lemon juice but some other more powerful aspect of our procedure that controlled the ruminating.

I had a chance to find out the day we began Claudia's

walking sessions. Georgianne was struggling with Claudia in the ill-fated assisted walking program. I approached with the wash bottle of lemon juice, held it up, and sweetly offered it to Claudia. The struggling ceased and she continued walking; Georgianne did not let go, however, remembering our experience in the hall earlier that day. When Claudia reached me, I gently squeezed a squirt of the lemon juice into her mouth, caressed her hair, and told her what a good girl she was. She did not flinch or jerk away as she always did when we swooped down on her after a rumination. We sat her down and I induced her to make eye contact repeatedly in return for squirts of lemon juice delivered in this gentle manner.

The results were not surprising. Researchers in the

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the events usually used to decrease behavior rates can also-when programmed differently-- serve to reinforce behavior (Kelleher & Morse, 1968; Morse & Kelleher, 1970; Plummer, Baer, & LeBlanc, 1977; Solnick, Rincover, & Peterson, 1977).

In hindsight, I realize that I could have been more thorough. For example, T could have replaced the lemon juice with fruit juice and continued with the wash bottle procedure, observing the effect upon rumination frequency. The simple demonstration with the lemon juice, however, convinced me to alter our intervention strategy. I reasoned that the manner of delivery was the relevant aspect of the procedure, an excited, rapid jab with the wash bottle versus a gentle slow squeeze. The amount and kind of juice were identical but the results markedly different.

We disposed of the wash bottle. With the new training programs it was a nuisance to carry and besides, it leaked. We used our hands instead, holding her cheeks between thumb and third finger, pointing at her tongue with the index finger. We administered this consequence as we had the lemon juice, quickly and sternly.

For several days, the rumination frequency rose slightly but remained well within the range displayed since training began (Figure 13, phase I). It returned thereafter to its usual low level and we continued without the lemon juice. Reversal and Return to Intervention

By June,.there was still no change in the rumination rate,, and we thought that we had decreased it as much as possible.







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It therefore seemed a likely time to abandon the cheek-hold procedure. 'We agreed to ignore the rumination and continue all other aspects of Claudia's training. Not wishing to inadvertently reinforce the rumination, we planned to discontinue for several minutes any session in progress when a rumination occurred.

The ruminating did not increase during the first two days (Figure 13, phase J). on the third day, however, Claudia averaged one rumination per twenty minutes, a rate equalled or exceeded only in the first two days of the original intervention. In the following week, the rate dropped, climbed, dropped, and climbed again. Overall, it was slightly but noticeably higher than during intervention. We knew that this outcome was likely. We had not decreased the rumination rate to zero and Claudia had therefore immediately contacted the procedural change-- she ruminated without consequence in the presence of her trainers. We were not alarmed, however. Research had shown that response-reduction procedures could be eliminated, then reinstated with no loss in effectiveness (Azrin & Holz,,1966). While we did not worry, neither were we willing to wait. We well remembered Claudia's appearance four months earlier. We reinstituted the cheekhold procedure and left it permanently in place (phase K).

The rumination frequency gradually declined. In November, 1977, eleven months after we had resumed holding Claudia's cheeks, there were more days during which we saw no rumina t4 on than there were days on which rumination occurred. By January,. 1978, several weeks would pass between ruminations. -





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In the summer of 1978, milk was briefly reinstituted in Claudia's diet; it had been removed at the same time as was Sustacal. The rumination frequency rose slightly but perceptibly (phase L)# so milk was permanently removed from her diet (phase M).

As the likelihood of rumination decreased, we gradually reduced the amount of Claudia's training time. We were eventually able to safely return her to the cottage living wing within one to one and a half hours after each meal. Whenever we felt she was ready for a decrease in training time, we spent several weeks monitoring her in the living wing. We would return her to the day room and leave, then q etly enter through a side door and station ourselves out of sight. We observed no rumination during these periods.

Although the ruminations were few and far between, we never abandoned the cheek-hold procedure. There was simply no reason to do so. The procedure was all but unused anyway, since there were so few ruminations. However, when a rumination did occur, we felt it best to deliver the consequences to keep the rate as near zero as possible.

When the rumination had almost vanished, hiring new

trainers presented a problem. Our original trainers and those hired while Claudia was still ruminating daily understood the importance of the rumination procedure and had many opportunities to observe the response. Trainers hired later, however, operated under a handicap. They rarely saw Claudia ruminate and thus did not know what they were looking for. They also





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had difficulty understanding why members of the original staff became upset if a rumination occurred and the consequences were not immediately delivered. How could they understand? They had not known the other Claudia.

In the spring of 1976, we took our clients to a picnic at some lakeside property owned by Sunland. I brought along a camera to record this first of many outings we enjoyed over the next several years. When the pictures were developed we realized that we had not been keeping the most important records of all. These children had changed. Photographic documentation immediately became an integral component of the STARS Program. For some of the clients, like Claudia, the documentation came too late. I recorded on film many of her accomplishments in motor and self-care skills. But missing was the most obvious change of all, that caused by the reduction in rumination.

our new trainers did not know Claudia as she was before and we had nothing to show them save a blurry snapshot from her cottage records. Our charts precisely documented Claudia's progress but they did not reflect her transformation from a pale, wasted figure on the cottage floor to a healthy girl capable of learning many new things.


Advanced Ambulation Skills


talkingg Outdoors

When Claudia was able to walk the length of the'cottage

hall, we eagerly moved the session outdoors. A long, straight





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sidewalk runs from the street to Lilac's. front porch. It was ideal for increasing the distance'Claudia was required to walk on each trial. The sidewalk is level and was therefore a good place to teach her to walk on surfaces other than smooth tile. There were no bumps and slopes that her -poor balance could not accomodate.

We set up two small vinyl chairs not quite thirty feet apart. This was less distance than we required Claudia to walk indoors but seemed adequate in view of the radical change in environment. We used a procedure similar to that employed for indoor walking. We sat Claudia in one chair and put a spoonful of blend or her regular meal in the opposite chair, helped her to a standing position, and let her go. When she arrived at the other chair we simultaneously gave her the food and helped her sit down. After a brief rest, she returned to the first chair in the same manner. She made ten to fifteen one-way trips prior to each meal.

Claudia performed well for the first three days, then caught a twenty-four hour virus. When she regained her health, there was trouble. There was a crack in the sidewalk about twenty-three feet from the front porch and when she reached the crack she sat down. Although the crack was more prominent than the small spaces between successive blocks, the sidewalk had not buckled and thus presented no physical barrier. we stood her up and held her wrists as she crossed,, walking her back and forth over it. Still she failed to cross the crack without assistance;.so we moved the other